Democratic presidential hopefuls will once again take to the debate stage to offer their vision for America. If past debates are any indication, candidates will likely field questions about gun safety, immigration, climate, and of course, health care. Most candidates have released their own plans for the future of health care in America, the most left-leaning of which is Senator Bernie Sanders’ (D-VT) Medicare for All legislation which has served as a starting point for other candidate’s proposals (Mayor Pete Buttigieg’s plan is a riff off of the Senator’s, entitled, Medicare-for-All-Who-Want-It). Across the board, Democratic candidates are committed to covering all Americans by expanding government coverage either in conjunction with private companies or by phasing them out.
And while health care plans are reflections of the current needs of the American public — proposals for mental health care coverage or caps on prescription drug prices — few plans explicitly mention a growing segment of the workforce who would gain from the expansion of health care or potential introduction of a nationalized system: gig workers.
Studies show that the gig economy is growing, and advocates for health care expansion believe that coverage should not be contingent on employment status and the size, wealth, and generosity of their employer. Half of Americans are insured through their employers, leaving Medicare, Medicaid and the Affordable Care Act (ACA) to cover the rest of the population, though notably, that still leaves 30 million Americans uninsured.
Gig workers, known as “contingent workers” or those with an “alternative work arrangement” are independent contract workers, part-time workers and delivery or ride-share drivers. A 2017 study conducted by the Bureau of Labor Statistics (BLS) found that 16.5 million Americans are working full-time contract jobs, with few or no benefits or protections offered. Additionally, a study conducted by Upwork this year concluded that 35% of the American workforce engaged in freelance work, some full-time freelancing, others part time and some freelancing in addition to a full-time job. The number of gig workers is going up, and the number of Americans insured by their employer is going down.
Gig workers who don’t meet the federal income standard for Medicaid or live in a state that has not passed a Medicaid expansion are essentially earn too much to qualify for the federal low-income care or for a tax credit to purchase care on the Affordable Care Act marketplace. A study conducted by Stride Health found that 35% of gig workers are uninsured and of those 63% reported that the cost of insurance was too expensive. The study also found that 37% gig workers with coverage chose to forego care due to cost.
Diane Mulcahy, adjunct lecturer at Babson College and author of The Gig Economy, said that the nature of awarding health care coverage based on employment status creates an unfair playing field. “The whole system is rigged against independent workers and health care insurance is a critical benefit, one that really favors employees over independent workers,” Mulcahy said.
Candidate proposals that build upon the ACA like Vice President Biden’s, Mayor Buttigieg’s and Senator Amy Klobuchar’s plans would expand Medicaid at the federal level, allowing low-income gig workers who previously did not qualify for coverage to be eligible, according to the Urban Institute’s Linda Blumberg. High-income gig workers could purchase coverage through a public option, but since the plans maintain employer-based coverage, they don’t take what more progressive candidates might see as serious steps to lower out-of-pocket costs for consumers.
Building on a program like the ACA, where the coverage varies state to state, as Mulcahy noted, “may not be a good solution for all workers.”
In contrast, single-payer plans that promise low or no out-of-pocket costs like those of Senators’ Sanders, Warren, and Harris might be more appealing to gig workers, Blumberg said. While some details of each plan are still murky, the single player option would treat gig workers equally to those with full-time employment.
“For gig economy workers, a single payer plan would probably seem the easiest to them,” said Brookings Institute’s Rob Maxim.
Andrew Yang believes that tying health care to employers is also costly for business, that “company-subsidized health insurance costs are a major impediment to hiring and growth.” Moreover, his website states that, “Health insurance also pushes companies to make as many employees as possible into part-time gig workers or contractors,” meaning that gig workers are used as scapegoats by insurance companies to save a corporation money.
There’s been a lot of conversation around strengthening labor laws to protect a worker’s ability to bargain and how companies classify employees in the first place. A senate bill to ensure and protect the rights of domestic workers sponsored by candidates Harris, Booker, Klobuchar, Sanders and Warren, notes that independent contractors are excluded from civil rights and labor protections. The bill, like California’s AB5, protects domestic workers from being misclassified by their employer, but few candidates have actually addressed protections for workers who aren’t misclassified, for whom the nature of their work is truly contract work. Mulcahy notes this doesn’t affect a freelance worker reporting to multiple entities or someone working part-time.
By and large, Americans are in favor of government-run health care programs like Medicare and Medicaid. A CNBC poll showed a majority of Medicare and Medicaid recipients thought their care was working well and would choose to re-enroll if they become uninsured.
Freelance writer Naomi LaChance says that she’s currently covered under her parent’s insurance plan, but that she’ll have to reevaluate her “entire career situation” when that is no longer the case and turns 26.
She supports Senator Sanders’ Medicare-for-All platform.
“I don’t think anyone likes having their health insurance linked to their work. It gives employers far too much control over our labor and our ability to quit. I’m ready for corporate greed to be taken out of the health care system entirely,” LaChance said.
The question of how to expand health care to ensure affordable coverage is fundamentally about the labor market and which workers we value, Mulcahy explained. “We need to fundamentally restructure our labor laws in order to support everybody who works. This idea of only supporting employees is outdated and needs to be reformed.”
Austin-based freelancer Stef Schrader is looking for full-time employment largely for health care benefits.
“My dad had a heart attack when I was a kid, and the debt totally upended our lives. It’s probably why my current insurance situation terrifies me so much,” she said.
No matter the health care plan, whether it includes an expansion of the ACA, Medicare or a public option, health care coverage for all Americans would establish a standard of “portable benefits,” which essentially means you have access to the same benefits even if you change jobs, become unemployed or go back to school. If adopted, benefit portability could change the relationship workers have with their employers by allowing them to move between jobs without having to switch health care, retirement or benefit plans.
“We have to view work in this country differently, and that means dealing with everything from portable benefits to how we’re going to deal with retirement security,” Senator Cory Booker, who is a proponent of Medicare for All, told CNN in June.
The rise of gig workers has challenged the way Americans look at health insurance, but 2020 candidates have yet to bring it to the debate stage with a real sense of urgency. Addressing this gray area would allow them to speak directly to a growing group of Americans who would greatly benefit from health care that’s not contingent on an employer.
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